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Why it’s important to verify your patients' eligibility and benefits for 2016



December 04, 2015
Area(s) of Interest: Practice Management 

With the new year soon upon us, physicians are urged to be diligent in verifying patients' eligibility and benefits to ensure they will be paid for services rendered. The beginning of a new year means calendar year deductibles and visit frequency limitations reset. With open enrollment there may also be changes to patients’ benefit plans, or patients may even be covered by a new payor.


The new year also brings a host of other challenges that could affect your ability to be paid:



  • Medicare patients can modify their enrollment choices from October 15 through December 7, allowing them to switch between Medicare fee-for-service and Medicare Advantage, or switch from one Advantage plan to another.



  • The Covered California open enrollment period began November 1 and runs through January 31, 2016. Covered California estimates it may enroll more than 300,000 new enrollees during the 2016 open enrollment period. However, existing enrollees also have the option to change plans and/or products.


Along with the 10 existing plans, two new plans are offering coverage on the exchange in 2016. United Healthcare and Oscar are entering the exchange marketplace for 2016 in select regions.


It’s important that physicians and their staff understand their participation status in the various exchange products offered in their areas in order to advise patients before scheduling as to whether they are participating in the patients' plans. For detailed instructions on how to check physician participation status, see CMA’s toolkit, Covered California: Know Your Participation Status, free to CMA members in our exchange resource center. Contact information for each exchange plan is also included in the toolkit, should practices have additional questions about participation status.


Don’t get stuck with unnecessary denials or an upset patient. Do your homework before the patient arrives by obtaining updated insurance information at the time of scheduling, if possible, and making copies of the insurance card at the time of the visit.


And don't forget that deductibles are typically based on the calendar year and will reset on January 1. Many of the exchange/mirror plans have high deductibles (e.g., $5,000 deductible on the Bronze plan), as do some employer-based plans. This reinforces the importance of verifying patient eligibility – particularly for exchange patients – each time they are seen. Best practice is to communicate with patients upon scheduling to remind them that their plan has a deductible that may be resetting on January 1 and, if that is the case, payment will be due at the time of service. If you offer an appointment reminder service, remind the patient if payment is expected at the time of service. Failure to collect deductibles, copays and coinsurance at the time of service can be very costly for a practice as your ability to collect can decrease significantly after the patient leaves the office.


Taking these proactive steps to protect your practice by preventing denials, delays in payment and disgruntled patients goes a long way toward ultimately saving time and money. 

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